The advancement of postoperative chemotherapy for gastric cancer patients has increased the 5-year survival rate to 68% (Waters et al., 2014). Although the combination of surgery and chemotherapy has also saved patients’ lives, the high postoperative recurrence and metastatic rates have caused a great psychological burden, thus generating a negative psychological event (Waters et al., 2014), such as fear. The fear of a cancer reoccurring is defined as “fears and concerns in patients with cancer regarding a possible future recurrence of cancer and/or metastasis and/or progression” (Lebel et al., 2016). Simard et al. (2010) reported that about 72% of patients experienced different degrees of fear of cancer recurrence, of which about 46% were at the mild or moderate level, and about 7% had severe fears.

To the best of our knowledge, no psychological intervention programmes specifically studied the fear of cancer recurrence in Chinese patients with gastric cancer. To date, only one study conducted a cross-sectional survey investigating the fear of cancer recurrence in patients with gastric cancer, utilising a multiple linear regression analysis (Sicheng, 2020). The results demonstrated that the self-disclosure and intimacy of patients were influencing factors for their fear of cancer recurrence (Fan, 2021). Most programmes have focused on the impact of self-disclosure on the patient’s psychological aspect, ignoring the role of their spouse in the psychological state (Zhang et al., 2019; Rabin, 2020; Rafii et al., 2022), and thus, have failed to treat the patient and their spouse as a unit (Dandan et al., 2018). However, a spouse’s high level of fear of cancer recurrence not only affects the spouse’s own physical and mental health but deeply affects the patient’s health (Wang Dongyu et al., 2021).

Marital self-disclosure, also known as Open communication, refers to the ability of one partner to express his/her feelings or thoughts to the other person and to ask for responses for coping (Porter et al., 2009). Emotional disclosure is a central component of the marital emotional support that partners provide to each other (e.g., love, concern, and understanding; Porter et al., 2009). Married patients with cancer tend to regard their spouse as their most important confidant, and their marital intimacy is positively correlated with disease adaptation and psychological adjustment (Lepore and Revenson, 2007; Kershaw et al., 2008; Hagedoorn et al., 2011; Zhang, 2019). Discussing cancer-related issues as a couple may help partners better understand the patient’s needs and provide more effective support. Additionally, the partner may feel relief when the patient shares his/her concerns (Porter et al., 2019). Our research team conducted a systematic review, analysing 13 RCTs and found that although the structure and themes of marital self-disclosure are different, compared with cancer education and standard psychosocial care, psychosocial support and marital self-disclosure interventions had potential benefits on physical and psychological health, marital relationship, and self-disclosure ability. Additionally, compared to routine care, marital self-disclosure was shown to have certain benefits in alleviating the fear of cancer recurrence in breast cancer patients.

Therefore, it is critical to develop a feasible, effective, and reliable programme to alleviate the fear of cancer recurrence in Chinese patients with gastric cancer and their spouses to encourage remedial or preventive measures. Due to significant differences in race, cultural background, religious belief, and economic status between populations in the Western hemisphere versus China, it would be inaccurate to directly apply interventions for a married person with a Western cultural background to the Chinese population. The adaptability and accuracy of relevant theories, evaluation scales, and analysis of influencing factors must be carefully considered before concluding. Furthermore, research findings from other types of cancers cannot be generalised to patients with gastric cancer. Therefore, a tailored marital-based self-disclosure programme for Chinese patients with gastric cancer needs to be developed. Meanwhile, psychological intervention by psychiatrists or oncology mental health counsellors is costly, and resources are limited, making it difficult for every patient with psychological distress to receive prompt attention. Psychological nursing is one of the routine tasks of oncology nurses; they need to care for patients every day and spend a long time with them, making it easy to identify patients’ psychological distress (Lu, 2022). Nurses who have undergone psychological training can simultaneously possess knowledge of oncology and psychology, making them easily accessible resources for patients seeking psychological therapy. Therefore, it is necessary to establish a set of nurse-led psychological intervention methods tailored to oncology patients.

To achieve this, a literature analysis was first conducted to retrieve, screen, synthesise, and extract relevant content from existing literature. Interviews were additionally conducted with patients, their spouses, and nurses to develop a preliminary draft of a marital self-disclosure programme. Subsequently, utilising the Delphi method, experts in the fields of oncology, psychology, and gastroenterology were consulted to review and enhance the draft. Finally, the experts finalised the marital self-disclosure programme that aimed to alleviate the fear of cancer recurrence in patients with gastric cancer and undergoing chemotherapy.

The marital self-disclosure programme for patients with gastric cancer and their spouses was developed by analysing existing evidence, stakeholders’ interviews, and the Delphi method. During the first phase, the most up-to-date evidence on marital self-disclosure in patients with gastric cancer and their spouses was combined with outcomes from the stakeholder interviews to form the initial draft of the marital self-disclosure programme. In the second phase, the two-round Delphi method was employed to collect opinions from experts and refine items making up the content of the programme. This approach resulted in the development of a self-disclosure programme specifically designed to alleviate the fear of cancer recurrence in patients with gastric cancer and undergoing chemotherapy.

The Delphi method was utilised for consensus-building (Humphrey-Murto et al., 2017). It is an iterative process using several surveys in which researchers seek the consensus of experts by answering questions (McPherson et al., 2018). A two-round Delphi method was used to assess relevant experts across multiple regions in China, to establish a consensus for the marital self-disclosure programme that alleviated fear in patients with gastric cancer. This study complied with the Conducting and Reporting Delphi Studies (CREDES) standard (Jünger et al., 2017; Niederberger and Köberich, 2021).

The research team consists of six people, including two nurse managers, three nurses, and one researcher, of whom major in oncology, psychology, and the gastrointestinal system. The team members are mainly responsible for formulating research topics and programmes, compiling consultation structure and questionnaires for the experts, selecting the experts, and organising, summarising, and statistically analysing the consultation results. The research process for developing the marital self-disclosure programme is shown in Figure 1.

Thirteen experts were included in a consultation process utilising the Delphi method. These experts came from eight tertiary A-level hospitals in four provinces in China, with a wide geographical distribution. Two research experts specialise in psycho-oncology, while six are oncology nurses whose professional or research focus is in psycho-oncology. Among them, three are full-time psycho-oncology nurses with extensive experience in psychological care and counselling. Two are psychological counsellors (one works in outpatient services, the other in gastroenterology), both with rich experience in psychological counselling, especially for gastrointestinal cancer patients. The work content or research focus of these experts is suitable for consultation in this study. Of the 13 experts involved, 61.54% (8/13) hold a master’s degree or above, while 92.31% (12/13) hold senior titles. Despite having an intermediate professional title, one oncology nurse expert has 10 years of work experience and a broad research scope related to this study. Thus, she was also included in the expert consultation team.

Outcomes from the expert consultants demonstrated that the familiarity coefficient, judgement basis and authority coefficients of the programme were rated as good. This indicated that the experts were very familiar with the research content and possessed extensive experience in both theoretical and practical aspects of this field. Moreover, the experts scored the importance of each item at a high level, while their opinions were well-coordinated and consistent, suggesting that the opinions were credible and desirable.

Enhancing the dyadic coping ability of gastric cancer patients and alleviating their fear of cancer recurrence is crucial to motivate remedial actions. To date, there are limited psychological interventions that appear to be effective for alleviating the fear of cancer recurrence in patients with gastric cancer and their spouse. This is the first and only intervention programme with the explicit aim of improving the fear of cancer recurrence in Chinese patients with gastric cancer. The marital self-disclosure intervention programme focuses on personal emotional expression, social cognition expression, benefit discovery, and outlook on the future among survivors, patients, and their spouses.

Several advantages are present in the developed programme and are expected to contribute to its positive impact on alleviating the fear of cancer recurrence among the specific group of patients studied. As the programme was developed in collaboration with Chinese medical staff, and patients, it is culturally appropriate and relevant. This stakeholder input has enabled the programme to address the unique needs and concerns of patients with gastric cancer and undergoing chemotherapy in the Chinese context. According to Sicheng (2020), patients with gastric cancer in the first, third, and sixth stages of chemotherapy feared less of a cancer recurrence with more family support. Therefore, the current programme spans four chemotherapy cycles to encompass the early to late chemotherapy sessions. Furthermore, the programme involves providing communication training to patients and their spouses on self-disclosure. By mastering the methods of self-disclosure while married, couples can engage formally and effectively apply these techniques to everyday communication (Gremore et al., 2021).

The themes included in the self-disclosure programme were established appropriately and reasonably, considering patient willingness and information from relevant literature. This approach helps ensure that the themes are relevant to the needs and preferences of patients with gastric cancer and supported by existing research (Zhang et al., 2019; Wang Dongyu et al., 2021). Previous studies found that patients with cancer exhibited self-disclosure avoidance (Northouse et al., 2000) as well as social isolation (Ettridge et al., 2018). Therefore, the first and second self-disclosure themes were set around “Personal Emotional Expression” and “Social Cognition Expression.”

As positive psychology develops and research deepens, people have realised that negative life events, such as cancer, can also bring about certain positive changes for patients (Stanton and Bower, 2015), such as cultivating healthy lifestyles, establishing new social relationships, and increasing disease knowledge. Wang et al. (2015) refer to these positive changes brought about by illness as “benefit finding” (BF). Planning positively for the future and guiding couples to adopt a positive outlook on cancer recurrence can encourage them to adjust negative emotions, change unhealthy habits, and plan for future family and social integration. Therefore, this study takes “Benefit Discovery” and “Outlook to The Future” as disclosure themes, aiming to alleviate the psychological trauma and stress caused by illness, encourage patients to face the disease with optimism, adopt effective behaviours to cope with the disease and contribute to physical and mental recovery. This has significant implications for reducing the fear of cancer recurrence (Stein et al., 2014; Cavell et al., 2016). Therefore, in addition to emotional disclosure, intervention themes also included “Benefit Discovery” and “Outlook to The Future. “The programme also combines both verbal and written self-disclosure to address the needs of patients who may struggle to verbally express or partially conceal their emotions. By using written self-disclosure, patients are encouraged to fully and accurately express their fears and concerns about cancer recurrence (Zhang et al., 2019; Yucel et al., 2021; Boyd et al., 2022).

Finally, this marital self-disclosure intervention programme was specifically designed for implementation by nurses, possibly appealing to medical staff seeking greater flexibility and inclusivity in their work. This intervention equips nurses with the necessary skills to teach patients and their spouses to apply theories of respect, empathy, and positive attention in emotionally driven communication and marital interactions. With this approach, nurses can also establish stable, friendly, and trusting relationships between themselves as caregivers and patients.

Several limitations have been identified in the current study. Firstly, it is important to note that the field of marital self-disclosure intervention is relatively new, with only a limited number of scholars specialising in this area, including the 13 experts included in the study. However, the selected experts have extensive and relevant experience spanning over 10 years and a strong research background. As a result, the content of the current marital self-disclosure programme can be regarded as highly authoritative and informed by a wealth of expertise.

Secondly, the marital self-disclosure programme for couples was only developed using the Delphi method and has not yet been tested on patients with gastric cancer and their spouses. Therefore, its effectiveness in this specific context is currently unknown. To address this gap, further research utilising a randomised controlled trial (RCT) research is necessary to rigorously evaluate the programme’s effectiveness.

Lastly, this research represents a long-term programme and, thus, requires a few practical considerations to be addressed. For instance, ensuring patient compliance during the implementation process and integration into regular nursing work without compromising efficiency. Moreover, all experts involved in this Delphi method study were of Chinese ethnicity, limiting the programme’s applicability and generalizability outside China.

In this study, the preliminary draft of the marital self-disclosure programme was developed through literature analysis and stakeholder interviews. The final programme was developed after two rounds of expert consultation, and the results were credible and reliable. The marital self-disclosure programme can be potentially applied to patients with gastric cancer and their spouses, to evaluate its impact on alleviating the fear of cancer recurrence. To further validate the programme’s effectiveness, feasibility, and generalizability, a health economics evaluation could be conducted. The evaluation would provide valuable insights into the costs and benefits associated with the programme, and help determine whether it is a viable intervention for a broader patient population.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

The studies involving humans were approved by the Ethics Committee of Jingjiang People’s Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

YZ: Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. CC: Writing – review & editing, Supervision. MC: Writing – review & editing, Supervision. HZ: Writing – review & editing, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization.